Basic Information
| Provider Information | |||||||||
| NPI: | 1750786059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUCKEBY | ||||||||
| OtherFirstName: | SARAH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1924 PINNACLE POINTE WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655845762 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2988 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 2626 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 2626 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3672PA | 05 | SC | MEDICAID |